| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,387 |
421 |
$100K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
941 |
313 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,109 |
314 |
$60K |
| D1110 |
Prophylaxis - adult |
1,435 |
1,409 |
$48K |
| D2394 |
|
302 |
93 |
$39K |
| D4341 |
|
683 |
175 |
$28K |
| D0330 |
Panoramic radiographic image |
709 |
586 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,080 |
916 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
218 |
100 |
$21K |
| D2950 |
|
377 |
163 |
$20K |
| D0274 |
Bitewings - four radiographic images |
984 |
964 |
$19K |
| D2332 |
|
128 |
49 |
$14K |
| D4342 |
|
222 |
62 |
$13K |
| D2335 |
|
275 |
87 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,440 |
1,098 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,322 |
1,185 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
714 |
710 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
306 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
118 |
$4K |
| D0251 |
|
106 |
78 |
$4K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
248 |
235 |
$0.00 |
| D1330 |
|
18 |
16 |
$0.00 |